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MELLON  LECTURE 

(UNDER  THE  AUSPICES  OF  THE  SOCIETY  FOR  BIOLOGICAL  RESEARCH) 

UNIVERSITY  OF  PITTSBURGH 


FOURTH  LECTURE 


THE  PROBLEM  OF  THE  RECONSTRUCTION 

AND  RE-EDUCATION  OF  THE 

DISABLED  SOLDIER 


BY 


ROBERT  W.  LOVETT 


1918 


THE   PROBLEM  OF  THE  RECONSTRUCTION 

AND  RE-EDUCATION  OF  THE 

DISABLED  SOLDIER 

BY 

ROBERT  W.  LOVETT,  M.D> 

JOHN  B.  and  BUCKMINSTER  BROWN.  PROFESSOR  OF  ORTHOPEDIC  SURGERY. 

MEDICAL  SCHOOL  OF  HARVARD  UNIVERSITY;    MAJOR 

MEDICAL  RESERVE  CORPS,  U.S.A. 


FOURTH  MELLON  LECTURE,  DELIVERED  BEFORE  THE  SOCIETY 

FOR  BIOLOGICAL  RESEARCH,  UNIVERSITY  OF 

PITTSBURGH,  MAY  10,  1918 


MELLON  LECTURE 

(UNDER  THE  AUSPICES  OF  THE  SOCIETY  FOR  BIOLOGICAL  RESEARCH) 

UNIVERSITY  OF  PITTSBURGH 


FOURTH  LECTURE 


THE  PROBLEM  OF   THE   RECONSTRUCTION 

AND  RE-EDUCATION  OF  THE 

DISABLED  SOLDIER 


BY 


ROBERT  W.  LOVETT 


i' 


1918 


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VK 


l.^ 


THE    PROBLEM     OF     THE     RECON- 
STRUCTION AND  RE-EDUCATION 
OF  THE  DISABLED  SOLDIER 

By  ROBERT  W.  LOVETT 

Professor  of  Orthopedic  Surgery  in  Harvard  Medical  School 
and  Major  Medical  Reserve  Corps,  U.  S.  A. 


A 


PPROXIM  ATELY  a  year  ago  the  United 
States  entered  the  European  War. 
During  that  year  hundreds  of  thou- 
sands of  young  men  have  left  their  homes, 
their  people  and  their  occupations  and  have 
entered  the  service  of  the  United  States  to 
fight  its  battles.  These  men  were  not  only  in 
the  most  active  and  vigorous  period  of  life, 
but  having  been  examined  for  physical  sound- 
ness before  entering  the  army,  they  represent 
a  highly  selected  class  of  sound,  active  in- 
dividuals of  great  value  to  the  community. 

The  experience  of  Canada  has  shown  that 
out  of  every  million  men  sent  overseas,  ioo,- 
ooo  or  10  per  cent,  will  have,  within  one  year, 
been  sent  home  as  unfit  for  further  military 
service.  Of  the  100,000  thus  sent  home, 
80,000  will  be  able  in  most  instances  to  return 
to  their  former  occupations.  The  other 
20,000  will  have  been  so  badly  disabled  that 
they  cannot  return  to  their  former  trade  or 
occupation  and  must  be  partly  or  wholly 
re-educated  to  some  new  one. 

The  governments  at  war  recognize  their 
responsibility  to  return  these  men  to  civil  life 
in  as  nearly  as  possible  the  same  condition  as 
that  in  which  they  were  taken  from  it.  It 
may  be  possible  to  return  them  on  a  higher 
level  of  economic  value  or  it  may  be  on  a 
lower  level,  but  it  has  been  definitely  estab- 
lished that  each  government  concerned  will 


468075 


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do  its  utmost  to  restore  to  each  disabled  man 
the  highest  degree  of  economic  efficiency 
attainable,  not  as  an  act  of  charity  but  as  a 
discharge  of  a  legitimate  indebtedness.  The 
present  address  deals  with  the  means  by 
which  this  is  to  be  accomplished. 

The  problem  concerns  the  public  in  two 
ways.  First,  there  are  few  homes  where  some 
near  or  distant  relative  or  friend  is  not  or  will 
not  be  in  the  service  and,  second,  the  success 
of  the  movement  to  be  described  here  must 
depend  finally  upon  sound  public  sentiment 
and  the  education  of  the  public  to  an  appre- 
ciation of  the  character  and  gravity  of  the 
problem  to  be  met.  For  this  reason  before 
discussing  the  specific  question  of  ways  and 
means,  something  must  be  said  of  the  proper 
attitude  of  the  public  toward  these  returned 
disabled  men.  Those  soldiers  who  return 
without  an  arm  or  a  leg  or  with  a  disabled  or 
useless  limb  are  not  to  be  regarded  as  poor 
cripples  to  be  commiserated  and  set  apart 
as  unfortunates  whose  usefulness  is  ended. 
They  will  not  in  the  future  be  compelled  or 
allowed  to  sell  lead  pencils  or  boot  laces  on 
the  street  corners  as  their  most  suitable 
occupation.  They  are  rather  to  be  regarded  as 
public  spirited  citizens  who  have  incurred 
some  physical  disability  in  the  pursuit  of  their 
service  to  their  country,  a  disability  to  be 
regarded  as  a  badge  of  honor  rather  than  as  a 
physical  defect.  This  disability  in  most  cases 
can  be,  in  greater  or  less  measure,  compen- 
sated for  by  proper  treatment  and  training, 
and  in  many  instances  the  disabled  man  will 
find  himself  in  a  position  to  earn  better  wages 
than  ever  before  in  his  life.  To  substantiate 
this  somewhat  optimistic  point  of  view,  one 
may  quote  briefly  French  and  German  ex- 
perience. 

6 


The  loss  of  an  arm  of  course  constitutes  a 
more  serious  problem  industrially  than  the 
loss  of  a  leg.  At  the  school  at  Lyons,  toy- 
making  and  parts  of  bookbinding  are  taught 
to  one  armed  men.  At  Montpellier,  wood 
turning,  tailoring  and  boot  making  also 
proved  available.  Of  other  occupations  for 
such  men  are  basket  work,  drawing,  horti- 
culture, telegraphy,  clerical  work,  stenog- 
raphy, etc. 

With  regard  to  the  loss  of  a  leg,  the  experi- 
ence of  the  English  Soldiers  and  Sailors  Help 
Society  is  of  importance.  They  consider  "  that 
the  loss  of  one  leg  does  not  debar  a  man  from 
being  quite  as  useful  as  he  would  be  with 
two  legs,  provided  a  little  care  is  taken  with 
him  in  the  early  stages;  and  we  consider  that 
if  we  were  to  take  two  men,  the  one  having  all 
his  limbs  and  the  other  minus  a  leg,  we  should 
be  more  successful  with  the  man  minus  a  leg 
than  with  the  able  bodied  one,  for  this  reason, 
that  the  man  with  one  leg  realizes  that  he  is 
not  quite  so  useful  as  the  other  man  and 
therefore  lays  himself  out  to  be  as  useful  as 
he  can  possibly  manage  to  be.  We  can 
arrange  suitable  work  for  men  who  have  lost 
both  legs:  it  is  only  a  matter  of  getting  a  man 
onto  his  bench  or  into  his  chair  each  morn- 
ing.'" 

The  attitude  of  regarding  these  disabled 
men  as  in  any  way  objects  of  charity  is  wholly 
improper  and  unjust  and  should  be  con- 
demned. They  have  earned  the  right  to 
every  care,  every  privilege,  and  every  assist- 
ance that  we  can  give  them.  They  have 
fought  our  battles  at  the  front  during  the  war 
and  we  should  regard  it  as  our  privilege  to 
fight  theirs  at  home  after  it.  Nor  should 
there  be  too  large  an  element  of  sentimentality 

1  Hutt.  Am.  J.  Care  of  Cripples,  191 7,  June. 


and  emotion  in  dealing  with  the  problems 
mentioned.  Heroes  these  men  are,  but  they 
will  be  better  served  in  the  end  if  the  public 
regards  them  rather  as  men  whose  wage 
earning  capacity  has  been  impaired,  men 
to  whom  it  is  due  that  every  effort  be  made 
to  make  this  diminution  as  little  as  possible. 

"In  one  of  the  allied  countries  the  wife  of  a 
returned  soldier  complained  to  the  repre- 
sentative of  a  patriotic  relief  agency,  which 
had  been  attending  to  the  family  needs  while 
the  chief  breadwinner  was  at  the  front,  that 
her  husband  would  never  spend  any  time 
with  her  or  the  children.  She  had  wanted  that 
afternoon  to  have  him  accompany  them  to 
the  park  but  he  disdainfully  refused,  saying 
that  he  was  going  out  for  an  automobile  ride 
and  later  to  a  '  sing  song '  at  one  of  the  fash- 
ionable hotels.  The  musical  entertainment 
referred  to  was  being  provided  by  the  society 
ladies  of  the  city/'1 

This  problem  of  the  attitude  of  the  public 
and  of  educating  it  to  better  things  is  of  very 
great  importance  because  the  cripple  of  the 
past  has  been  regarded  askance,  as  a  poor 
unfortunate,  greatly  to  be  pitied,  to  be  stared 
at  in  public  and  petted  and  spoiled  in  private. 
This  attitude  is  well  presented  in  a  novel 
which  was  in  vogue  some  years  ago  called 
Sir  Richard  Calmady  by  Lucas  Malet,  where 
the  crippled  hero's  disability  and  peculiarities 
are  harped  on  and  discussed,  dwelt  on  at 
every  turn  and  his  life  is  centered  around  his 
peculiarity,  which  is  constantly  emphasized 
by  all  those  about  him.  So  well 'does  it  em- 
body all  that  we  ought  to  condemn  that  I 
have  often  asked  classes  of  medical  students 
to  read  the  book  in  order  to  learn  what 
attitude  to  avoid. 

*  McMurtrie.   The  War  Cripple.   Col.  War  Papers,  Ser.  i,  No.  17. 

8 


Take  rather  as  a  model  of  what  is  desirable, 
the  attitude  of  a  young  woman  of  twenty-six 
who  appeared  at  a  recent  orthopedic  clinic 
held  in  connection  with  the  Army  Medical 
School  in  Washington,  whose  story  only  came 
out  when  she  was  questioned  in  the  amphi- 
theatre. She  had  been  injured  in  an  auto- 
mobile accident  six  years  ago  when  an  over- 
turned car  had  pinned  her  beneath  and  had 
fractured  her  spine.  An  unsuccessful  opera- 
tion had  been  performed  and  since  the  day  of 
her  accident  she  had  been  wholly  paralyzed 
from  the  waist  down.  For  the  first  year  she 
had  been  treated,  but  for  five  years  nothing 
had  been  attempted.  With  casters  put  onto 
an  ordinary  kitchen  chair  she  had  managed  to 
do  the  housework  for  a  family  of  five.  She  had 
done  the  cooking,  made  beds,  swept,  scrubbed, 
cleaned  paint,  washed  windows,  done  some 
gardening  and  had  so  far  as  I  could  learn 
done  all  these  things  without  a  thought  of 
commiserating  herself  or  asking  for  sympathy 
or  assistance.  Some  friend  had  insisted  on  her 
coming  to  the  clinic.  Contrast  this  healthy 
minded  attitude  with  the  morbid,  shrinking, 
self-indulgent,  self-conscious  attitude  so  often 
possessed  by  the  cripple,  and  see  what  a  great 
advantage  there  is  in  inducing  people  to 
adopt  the  healthy  and  sane,  rather  than  the 
morbid  and  commiserating,  view  toward  these 
returning  soldiers. 

So  strongly  do  I  feel  the  disadvantage  of 
dwelling  too  much  on  the  term  cripple  that  in 
this  address  it  will  be  my  attempt  to  avoid  the 
term  "crippled  soldier,"  so  much  in  vogue  in 
the  newspapers,  and  to  speak  only  of  the 
disabled  soldier. 

Having  thus  considered  the  spirit  in  which 
the  matter  should  be  approached,  we  may 
come  to  the  closer  consideration  of  the  prob- 


lem  itself.  The  term  most  often  applied  to 
meet  the  situation,  and  perhaps  the  best,  is 
Reconstruction.  The  word  reconstruction  is 
also  applied  to  the  repair  of  the  devastated 
regions  in  France  and  Belgium,  such  as  the 
rebuilding  of  villages,  the  refurnishing  of 
farms  and  houses,  the  replanting  of  orchards, 
etc.,  which  activity  is  perhaps  equally  en- 
titled to  the  use  of  the  word  reconstruction, 
but  this  double  use  leads  to  confusion  and 
confusion  will  in  the  end  prove  detrimental 
rather  than  beneficial  to  both  interests. 

In  this  instance  the  term  reconstruction 
will  be  used  to  designate  the  attempt  to  re- 
habilitate and  if  necessary  re-educate  the  man 
who  has  been  physically  disabled.  This 
attempt  will  fall  into  three  divisions  which 
are  almost  self-evident.  First,  the  returned 
soldier  must  receive  medical  and  surgical 
attention  to  determine  whether  he  needs  fur- 
ther operation  and  if  he  does,  he  must  have 
it  performed.  Second,  many  of  the  men  with 
surgical  injuries  require  treatment  to  loosen 
up  joints,  develop  muscles,  free  tendons,  im- 
prove resistance  to  fatigue,  and  although  this 
is  partly  accomplished  by  massage  and  similar 
measures,  it  has  been  found  in  this  war  that 
it  is  better  brought  about,  when  possible,  by 
actual  work  either  in  bed,  bedside  occupations, 
or  in  shops  equipped  for  the  purpose  known  as 
curative  workshops  in  which  an  occupation  is 
pursued  which  is  of  itself  curative.  Third, 
the  disabled  man  must  in  a  certain  number  of 
instances  be  educated  to  a  new  trade  or 
occupation  inasmuch  as  he  may  be  unable 
to  follow  his  original  one  on  account  of  the 
nature  of  his  injury,  and  here  comes  in  the 
third  stage  of  reconstruction  activity  spoken 
of  as  "vocational  training"  or  " re-educa- 
tion." 


IO 


The  stages  of  reconstruction  may  be  tabu- 
lated as  follows: 

Medical  or  surgical  attention 

J  curative  workshops 
massage,     gymnastics, 
etc. 
acement  and  follow  up 

The  whole  question  of  reconstruction  in 
this  paper  will  be  discussed  largely  from  the 
point  of  view  of  the  orthopedic  surgeon,  not 
because  it  is  the  only  point  of  view  but  be- 
cause it  is  the  one  with  which  the  writer  is 
most  familiar. 

Care  of  cripples.  At  the  beginning  of  the 
war  in  19 14  most  of  what  we  knew  about  the 
possibility  of  restoring  usefulness  to  the 
disabled,  we  had  learned  from  our  attempts  to 
help  the  cripple,  or  the  crippled  child  whose 
functions  had  been  impaired  by  disease  or 
accident  or  by  some  congenital  defect.  In- 
dustrial schools  and  homes  for  cripples  had 
been  founded,  societies  in  Germany  and 
America  had  been  formed  for  the  study  of  the 
question  and  two  journals,  one  German  and 
one  American,  were  devoted  to  the  considera- 
tion of  the  subject.  Up  to  1832  the  cripple 
had  been  wholly  neglected  as  a  public  prob- 
lem but  in  that  year  the  Royal  Bavarian 
School  and  Home  for  Cripples  was  started. 
America  took  no  effective  action  in  the  matter 
until  some  sixty  years  later  when  a  private 
educational  and  industrial  school  for  cripples 
was  started  in  Boston.  That  was  in  1893  and 
represented  the  first  American  attempt  at 
re-education  along  useful  lines  although  there 
had  been  founded  three  homes  for  crippled 
children  in  the  preceding  few  years. 

When  it  came  to  convincing  the  public  that 
the  state  care  and  education  of  cripples  was 
advisable,  necessary  and  economical,  it  was 
surprising  to  see  what  public  inertia  one  en- 

11 


countered.  The  blind,  the  feeble-minded  and 
the  deaf  mutes  were  recognized  as  proper  sub- 
jects for  state  aid  and  instruction,  but  to  one 
who  was  concerned  in  an  attempt  to  convince 
the  Massachusetts  legislature  that  cripples 
were  entitled  to  similar  advantages,  the  un- 
willingness to  take  seriously  the  question  was 
surprising,  but  although  in  the  end  the  fight 
was  won,  only  four  states  have  provided  such 
state  care  and  education.  Minnesota,  New 
York,  Nebraska  and  Massachusetts  founded 
such  schools  in  the  order  named  between  1897 
and  1906  inclusive. 

Industrial  cripples.  The  care  and  rehabilita- 
tion of  the  man  crippled  in  industrial  work 
was  never  considered  in  America  a  public 
problem  and  he  has  been  from  the  outset 
neglected,  and  a  great  economic  error  has 
thereby  been  committed.  However,  that  will 
never  occur  in  the  future  for  the  lesson  of 
what  may  be  done  in  restoring  the  disabled 
soldier  to  usefulness  is  already  being  taken 
seriously  in  the  industrial  world  in  its  applica- 
tion to  those  injured  in  the  industries,  a  mat- 
ter which  will  be  discussed  later. 

Taking  the  situation  as  it  existed  in  19 14, 
we  had  learned  from  this  study  of  the  attempt 
to  improve  the  cripple  that  his  mentality  and 
outlook  were  unfavorably  influenced  by  his 
disability,  that  he  was  uneducated,  in  a  sur- 
prisingly large  proportion  of  cases  being 
wholly  illiterate,  that  trades  and  wage  earn- 
ing occupations  were  often  closed  to  him  in  his 
uneducated  condition,  but  that  in  many  in- 
stances by  proper  surgical  attention,  by  gen- 
eral education  and  by  special  training,  he 
could  be  made  a  wage  earner  and  a  useful 
citizen  instead  of  being  a  burden  on  his  family 
or  becoming  an  almshouse  charge.  The  pa- 
tient with   paralyzed   legs   and   consequent 


12 


inability  to  get  about  actively  is  just  as  useful 
as  anyone  else  as  a  typesetter,  leather  worker, 
or  a  designer.  A  girl  with  paralysis  of  both 
arms  in  the  Massachusetts  Hospital  School  at 
Canton,  Massachusetts,  was  taught  to  use 
her  feet  as  hands  and  in  a  sewing  competition 
among  the  town  pupils  won  first  prize  for 
her  sewing  and  embroidery.  A  baseball  nine 
was  formed  at  this  school  and  in  a  series  of 
games  in  one  of  the  school  leagues  one  summer, 
this  team  won  two  games  out  of  every  three 
played  in  competition  with  healthy  boys  of 
their  own  age.  The  catcher  had  two  artificial 
legs  and  his  base  running  was  done  for  him 
by  a  boy  with  useless  arms  but  good  legs. 
Thus  through  the  nine  the  job  was  adapted  to 
the  disability  of  the  individual.  We  had 
learned  that  the  individual  within  proper 
limits  could,  to  a  large  extent,  be  edu- 
cated on  new  lines  and  that,  to  a  certain 
extent,  the  job  could  be  adapted  to  the  indi- 
vidual. 

In  England  an  attempt  to  salvage  disabled 
soldiers  was  begun  after  the  Boer  war  and 
workshops  were  established  by  the  Incor- 
porated Soldiers  and  Sailors  Help  Society  in 
London  which  after  the  death  of  Lord  Roberts 
were  called  the  Lord  Roberts  Memorial  Work- 
shops. The  object  of  these  shops  was  "to 
teach  useful  trades  to  men  discharged  as 
medically  unfit  who,  by  reason  of  their  dis- 
ability .  .  .  are  unable  to  take  ordinary 
employment  and  to  make  such  cases  as  far  as 
possible  self  supporting." 

There  should  be  added  to  the  knowledge 
existing  in  1914  derived  from  the  study  of  the 
cripple  and  from  the  experience  of  England 
just  mentioned,  a  small  amount  of  information 
from  a  few  schools  for  those  injured  in  indus- 
try,   such   as   that   at   Charleroi   under   M. 

13 


Basecme,  who  put  this  experience  into  use  in 
the  ficole  Joffre  in  Lyons.1 

With  this  stock  of  knowledge,  England, 
France,  and  Belgium  started  in  soon  after  the 
beginning  of  the  war  applying  the  facts  thus 
learned  to  the  repair  and  re-education  of  the 
disabled  soldier.  This  attempt  has  been 
attended  by  very  marvelous  results  and  in 
this  country  we  start  in  with  the  great  advan- 
tage of  being  able  to  draw  on  the  experience  of 
these  nations  in  meeting  a  problem  similar  to 
the  one  that  now  confronts  us.  The  data  here 
presented  are  necessarily  derived  from  the 
experience  of  these  other  nations. 

The  keynote  to  the  whole  situation  seems 
to  be  that  man  is  an  adaptable  animal, 
mentally  and  physically,  that  in  his  daily 
routine  he  is  probably  using  but  a  small  part 
of  his  real  capabilities,  that  his  life  occupation 
is  not  necessarily  the  one  for  which  he  is  best 
fitted  and  that  he  is  often  not  educated  up  to 
his  regular  job.  If,  therefore,  a  man  is  so  in- 
jured that  he  cannot  return  to  his  old  work, 
the  question  arises  as  to  what  work  he  is 
physically  and  mentally  fitted  to  perform  and 
among  such  jobs,  which  one  attracts  him. 
Moreover,  a  little  education  might  help  him 
to  a  better  job  within  limits  than  he  had 
before.  We  can  count  on  adaptability  as 
enabling  the  intelligent  man  to  adapt  himself 
to  his  work,  so  that  the  work  need  not  wholly 
depend  on  being  adapted  to  the  man. 

Progress  of  the  soldier.  To  take  up  now  the 
specific  problem  to  be  discussed,  we  must 
start  with  the  soldier's  injury.  The  man  who 
is  wounded  in  action  receives  his  first  surgical 
attention  from  the  regimental  or  battalion 
surgeon  at  the  first  aid  post,  generally  situated 
in  a  dugout  a  few  hundred  feet  behind  the  first 

*Hannan.   Contemporary  Review,  1916,  p.  105. 


line  trench.  Conditions  are  not  favorable  at 
this  place  for  more  than  first  aid.  He  then 
either  walks  or  is  carried  through  the  com- 
municating trenches  to  a  point  about  a  mile 
back  where  he  is  placed  in  a  motor  ambulance 
and  carried  to  the  field  ambulance  dressing 
station  about  three  miles  back  of  the  front 
line  trench.  Here  he  receives  an  inoculation 
against  tetanus,  his  wound  is  redressed,  he  is 
given  a  hot  meal  and  is  carried  on  in  a  motor 
about  five  miles  farther  to  the  casualty  clear- 
ing station.  Here  he  receives  his  chief  surgical 
attention,  he  is  X-rayed  if  necessary,  operated 
on  if  need  be,  perhaps  redressed,  put  in  bed, 
nursed,  fed,  and  cared  for  until  he  is  able  to 
be  transported  by  train  to  the  base  hospital,  a 
journey  of  some  hours;  and  in  this  base  hos- 
pital he  can  be  kept  as  long  as  need  be.  In 
general  it  has  not  been  found  advisable  in 
Canadian  experience  to  keep  a  man  in  Europe 
over  three  months.  A  man  obviously  perma- 
nently disabled  is  generally  returned  home  in 
about  two  months,  while  doubtful  cases  are 
retained  about  three  months  to  see  if  they  are 
likely  to  be  able  to  return  to  active  military 
service.  From  the  base  hospital  he  either 
returns  to  the  front,  after  perhaps  a  stay  in 
some  convalescent  home,  or  he  is  invalided 
home  as  probably  or  manifestly  unfit  for 
further  active  war  service. 

With  regard  to  the  number  of  men  who  are 
returned  to  the  front  for  active  service  from 
the  base  hospitals  in  the  year  ending  April, 
191 5,  the  Germans  claimed  from  87  to  91  per 
cent.  Data  made  early  in  191 7  by  a  Copen- 
hagen society  give  for  the  central  powers 
and  allies  about  70  per  cent  to  be  returned  to 
the  front.  It  is  stated  in  a  military  periodical1 
that  in  the  battle  of  the  Somme  there  were 

'Military  Surgeon,  1916,  Dec. 

IS 


some  2600  wounded  British  each  day  of  whom 
85  per  cent  returned  to  active  duty.  Well  in- 
formed authorities  regard  the  German  claims 
as  quite  exaggerated  while  others  would  place 
the  figure  at  80  per  cent  or  higher  on  the 
Western  front  for  both  allies  and  central 
powers.1  The  fact  is  that  there  are  as  yet  no 
reliable  data  available  on  which  to  base  an 
exact  estimate  but  there  is  no  great  doubt  that 
more  than  half  of  the  wounded  who  reach  a 
base  hospital  are  capable  of  returning  to  duty 
in  a  few  weeks.  An  English  estimate2  gives 
the  following  percentages:  In  the  so-called 
command  depot  at  Heaton  Park  within  a 
period  of  six  months  from  the  date  of  injury 
about  50  per  cent  rejoined  their  original  units, 
15  per  cent  were  sent  to  service  in  com- 
municating lines  abroad,  15  per  cent  were  use- 
ful for  sedentary  occupations  at  home  and 
somewhat  over  20  per  cent  were  discharged  as 
permanently  unfit,  many  of  these  having  been 
untreatable  from  the  outset.  Of  the  men  thus 
invalided  home,  Belgian  experience  has 
shown  that  80  per  cent  are  capable  of  voca- 
tional re-education,  while  20  per  cent  must  be 
regarded  as  permanently  incapacitated  for 
wage  earning  activity  on  account  of  the 
nature  of  their  injuries.  Of  those  who  are 
suitable  for  re-education,  45  per  cent  can  be 
made  to  earn  their  normal  wages,  20  per  cent 
can  be  partially  restored  and  can  earn  an 
appreciable  wage,  while  15  per  cent  can  be 
repaired  to  an  extent  to  earn  a  salary  which 
will  constitute  a  bare  livelihood. 

Method.  On  the  arrival  of  the  soldier  at  a 
home  port,  he  is  either  discharged  permanent- 
ly to  his  home  after  examination  or  is  sent  to  a 
reconstruction  hospital,  after  a  short  furlough 

1  Rubinow.   Red  Cross  Inst,  for  Disabled  Men,  Bulletin  No.  4. 
*  Mackenzie.   Brit.  M.  J.,  1016,  August  12. 

16 


at  home,  which  has  been  found  desirable  when 
it  is  practicable  and  the  soldier  is  able  to 
travel.  This  conduces  to  a  better  mental 
attitude  and  greater  content.  The  men  dis- 
charged permanently  are  those  who  are  unfit 
for  further  military  service  and  who  are  not  in 
need  of  further  surgical  or  therapeutic  atten- 
tion, most  of  whom  are  able  to  pursue  their 
former  lines  of  work  without  re-education. 

Of  the  returned  men,  75  to  85  per  cent  are 
to  be  classed  as  orthopedic.  The  definition  of 
orthopedic  as  established  by  the  ruling  of  the 
Surgeon  General  of  the  United  States,  of  Au- 
gust, 191 7,  a  ruling  which  is  in  general  accord 
with  the  English  and  Canadian  classification, 
is  as  follows:  (a)  derangements  and  disabilities 
of  joints  including  ankylosis;  (b)  deformities 
and  disabilities  of  feet;  (c)  malunited  and  un- 
united fractures;  (d)  injuries  to  ligaments,  mus- 
cles and  tendons;  (e)  cases  requiring  tendon 
transplantation  or  other  treatment  for  irre- 
parable destruction  of  nerves;  (f)  nerve  in- 
juries accompanied  by  fractures  or  stiffness  of 
joints;  (g)  cases  requiring  surgical  appliances. 

With  regard  to  the  various  forms  of  affec- 
tions which  have  disabled  these  men,  an  an- 
alysis of  about  3000  Canadian  returned  men 
was  made  in  191 5  with  the  following  percent- 
ages, which  may  be  taken  as  indicating  about 
what  we  may  expect: 

Per  cent 

Major  amputations 13 .9 

Other  permanent  injuries  to  extremities 26 . 7 

Other  injuries  and  wounds „ 12.2 

Eyesight  and  deafness  cases 13 

Diseases  of  chest  and  heart  and  rheumatism ....  23 . 8 

Nervous  diseases 4.7 

Miscellaneous  disabilities 5.7 

Generalizing  from  these  figures  Rubinow1 
estimates  that  in  an  army  of  one  million, 

1  Rubinow.   Red  Cross  Inst,  for  Crippled  and  Disabled  Men.    1918, 
Feb.,  Ser.  1,  No.  14. 

17 


operating  for  a  year,  some  40,000  men  may  be 
expected  to  be  disabled  through  serious  in- 
juries to  their  extremities  and  therefore  to 
require  special  placement  facilities  or  voca- 
tional re-education.  An  estimate  of  the  prob- 
able character  and  distribution  of  these  in- 
juries is  as  follows: 

Amputation  of  leg 7,ioo 

Amputation  of  arm 5,800 

Amputation  of  hand 700 

Injuries  to  leg  hot  requiring  amputation 9,500 

Injuries  to  arm  not  requiring  amputation 9,100 

Injuries  to  hand  requiring  partial  or  no  ampu- 
tation     7,800 

40,000 

Relation  of  soldier  to  military  establishment. 
The  first  serious  question  which  arises  at  this 
point  is,  What  shall  be  the'  relation  of  the  re- 
turned disabled  soldier  to  the  military  estab- 
lishment? Shall  he  remain  under  military 
discipline  or  shall  he  be  discharged?  If  he 
requires  no  further  treatment  and  can  return 
to  his  former  occupation  he  can  obviously  be 
discharged.  If  he  requires  further  treatment 
it  is  the  general  opinion  that  he  should  re- 
main in  the  army  and  under  military  dis- 
cipline until  such  treatment  is  nearly  or 
wholly  completed.  If  after  his  treatment  or 
toward  the  close  of  it,  he  requires  re-education 
or  vocational  training  for  a  new  occupation 
there  are  divergent  views  as  to  whether  he 
should  receive  this  from  military  or  civil 
sources. 

It  is  urged  in  favor  of  civilian  control,  (1) 
that  private  control  is  free  from  embarrassing 
limitations  due  to  legislation;  (2)  that  the 
services  of  experts  would  be  available  who  are 
not  available  for  government  service;  (3)  that 
the  use  of  private  funds  would  be  obtained; 
(4)    that   diverse   civilian   agencies   now   in 

18 


existence  could  be  utilized.  In  favor  ot  gov- 
ernment control  it  is  said  that  (i)  the  govern- 
ment has  charge  of  the  soldiers  when  they 
return  and  is  under  the  immediate  need  of 
providing  for  them;  (2)  experience  has  shown 
that  soldiers  so  far  as  possible  should  be 
rehabilitated  in  their  own  communities  and 
that  this  geographical  distribution  can  most 
easily  be  carried  out  by  the  government; 
(3)  if  military  control  during  re-education  is 
necessary,  the  government  alone  can  exercise 
that;  (4)  the  training  of  teachers  for  the  work 
should  be  carried  on  by  the  government; 
(5)  the  government  is  in  a  position  to  utilize 
agencies  which  civilian  control  could  not  com- 
mand; (6)  the  governmental  better  than  any 
other  control,  could  command  co-operation  in 
placing  these  men  in  positions  after  their 
rehabilitation  is  finished;  (7)  private  control 
implies  that  these  men  are  wards  of  charity 
rather  than  the  recipients  of  their  just  dues 
and  the  continuance  of  private  support  is 
precarious. 

Re-education  is  practically  obligatory  in 
Germany,  Austria,  Italy,  and  Belgium,  al- 
though even  in  these  countries  they  are  un- 
able to  persuade  a  certain  percentage  of 
disabled  soldiers  to  undergo  re-education.  In 
France  the  whole  matter  is  in  charge  of  an 
interministereal  commission  called  the  French 
National  Office.  The  training  offered  is  not 
obligatory  in  the  strictest  sense  because 
honorable  discharge  may  be  granted  before 
the  course  of  training  is  complete  and  after 
this  the  wounded  man  is  free  to  do  as  he 
pleases.  "Undoubtedly  some  means  will  have 
to  be  found  by  which  re-education  can  be 
made  to  hold  a  greater  appeal  to  disabled 
men."  x  Facilities  for  re-education  are  un- 

1  War  Dept.  Office  of  the  Surgeon  General.   Bulletin  No.  $~ 

19 


equal  to  the  demands,  inasmuch  as  France 
can  only  provide  for  7000  to  8000  men  each 
year  and  there  are  approximately  300,000  war 
disabled  to  date.  In  Great  Britain  when  men 
are  discharged  from  the  service,  they  are 
referred  to  a  local  committee.  Training  is  not 
compulsory  but  it  is  the  duty  of  the  local 
committee  to  urge  it  upon  disabled  men. 
Treatment  will  be  provided  at  the  state's 
expense  even  after  discharge.  If  he  refuses 
training  half  of  his  pension  may  be  withheld. 
During  training  he  is  paid  as  if  he  were 
totally  disabled  and  his  family  receives  the 
same  allowance  that  they  would  if  he  were 
dead.1 

It  would  seem  as  if  uniformity  of  conditions 
in  treatment  and  re-education  were  better 
insured  by  government  control  as  the  soldier 
is  then  in  the  hands  of  specialists  controlled  by 
the  medical  department,  he  is  associated  with 
other  men  similarly  handicapped  and  his 
tendency  to  self  commiseration  is  thereby 
diminished  and  he  is  far  less  likely  to  mental 
demoralization  than  if  he  were  turned  loose  to 
be  cared  for  by  private  charity  administered 
in  civilian  institutions. 

The  advantage  of  standardization  of  morale 
and  methods  is  great  and  this  would  imply 
that  if  government  control  of  these  men  is  to 
exist  they  must  be  treated  in  military  hos- 
pitals, and  that  civilian  institutions  could 
not  be  used  unless  wholly  turned  over  to  the 
government  for  the  purpose,  because  the 
utilization  of  civilian  institutions  would  mean 
civilian  control  of  men  in  service  or  a  divided 
control.  The  possibility  of  the ,  former  can 
perhaps  be  only  appreciated  by  those  who 
have  seen  the  returned  men  under  these  con- 
ditions.   After  months  or  years  of  hard  ex- 

1  Fanes.  Magazine  for  Care  of  Cripples,  1918,  March. 

20 


acting  work,  they  find  themselves  idle  and 
disabled  with  their  future  to  a  certain  extent 
unsettled.  They  resent  the  idleness,  they  are 
inclined  to  be  mentally  unstable  and  unruly, 
and  at  no  time  in  their  career  do  they  need 
a  firmer  hand  than  during  their  early  con- 
valescence. A  civilian  institution  filled  with 
such  patients  would  be  a  constant  state  of 
ferment,  unrest  and  inefficiency.  With  regard 
to  dual  control  of  such  institutions,  that  wa^s 
tried  out  in  Canada  where  the  hospital's 
commission,  a  civilian  board,  and  the  medical 
corps  shared  equally  in  the  control  of  the  re- 
construction hospitals.  The  disadvantages  of 
the  scheme  were  such  in  the  way  of  duplication 
of  all  administrative  machinery,  that  after 
one  or  two  changes  a  scheme  has  recently  been 
adopted  by  which  the  whole  matter  has  been 
placed  in  the  hands  of  a  new  department  of 
the  Government  of  Canada  known  as  the 
Department  of  Soldiers'  Civil  Re-establish- 
ment over  which  a  Minister  of  Soldiers'  Civil 
Re-establishment  presides.  The  duties  of  the 
department  comprise  the  providing  of  hos- 
pitals, convalescent  homes,  and  sanatoria;  the 
vocational  education  and  other  training,  and 
all  matters  relating  to  pensions  of  disabled 
soldiers. 

Civilian  institutions  are  naturally  anxious 
to  be  of  use  and  much  pressure  has  been 
brought  to  bear  on  the  government  to  use 
such  institutions,  but  it  would  seem  that  the 
best  results  were  to  be  obtained  if  returned 
disabled  soldiers  remain  in  the  army  and  are 
not  discharged  until  their  treatment  has  been 
nearly  or  wholly  completed,  and  that  this 
should  be  carried  on  in  military  institutions 
under  military  control,  so  far  as  proves  prac- 
ticable. It  will  often  happen  that  the  man's 
treatment  and  vocational  training  must  go 

21 


on  contemporaneously.  His  status  under 
these  conditions  will  have  to  be  determined  in 
each  individual  case,  but  the  weight  of  opinion 
is  to  the  effect  that  treatment  will  be  more 
effective  when  carried  out  under  military 
control. 

To  return  to  the  program  of  the  individual 
soldier.  At  the  conclusion  of  his  furlough  or  if 
no  furlough  is  practicable,  the  returned  dis- 
abled soldier  is  sent  to  a  reconstruction  hos- 
pital, and  it  is  important  that  idleness  should 
be  terminated  as  soon  as  may  be.  Here  he  is 
carefully  examined,  his  disability  investigated, 
and  analyzed,  his  needs  formulated,  the  ques- 
tion of  an  operation  to  improve  his  defect 
considered  and  if  necessary  performed.  After 
this  the  question  of  his  treatment  is  con- 
sidered. If  he  requires  an  artificial  limb,  his 
stump  is  prepared  for  its  application.  Very 
often  the  joint  of  the  hip,  for  example,  has 
become  stiffened  in  a  position  which  makes  it 
difficult  or  impossible  to  use  an  artificial  leg. 

The  artificial  limb  question  has  been 
settled  by  Canada,  by  the  establishment  of 
artificial  limb  factories  administered  by  the 
Government,  where  such  appliances  may  be 
turned  out  of  standard  pattern  at  a  cost  much 
less  than  that  asked  by  the  commercial  manu- 
facturers. These  limbs  are  fitted  under  the 
supervision  of  the  surgeon  and  the  patient 
instructed  in  their  use. 

If  stiffened  joints  exist,  the  question  of  their 
mobilization  arises  by  operation  or  thera- 
peutic means.  Paralysis  is  analyzed  and  the 
possibility  of  the  restoration  of  some  degree  of 
nerve  power  discussed.  Ulcers  from  wounds, 
badly  united  and  ununited  fractures  and 
similar  disabilities  are  placed  under  proper 
treatment  and  operated  on  if  need  be. 

Before  discussing  the  strictly  medical  and 


22 


surgical  aspect  of  the  treatment,  something 
more  must  be  said  of  the  psychology  of  the 
disabled  soldier.  He  has  been  living  under 
discipline,  under  great  stress  and  excitement 
at  times,  he  has  been  under  orders  and  has  not 
had  to  think  for  himself  when,  suddenly  he 
finds  himself  partially  or  wholly  disabled,  his 
former  occupation  can  perhaps  no  longer  be 
carried  on,  he  has  a  family  dependent  on  him 
and  his  future  is  uncertain,  he  is  inactive  and 
perhaps  has  to  remain  in  bed  for  weeks.  He 
must  not  be  classed  with  the  ordinary  hos- 
pital patient;  he  has  special  needs,  he  may  be 
unable  to  read  or  not  interested  in  being  read 
to,  while  for  games  or  cards  he  may  have  no 
aptitude,  yet  he  must  be  given  some  occupa- 
tion, and  here  comes  in  the  usefulness  of  the 
so-called  bedside  occupation  which  should  be 
begun  as  early  in  his  career  as  possible. 

The  so-called  bedside  aides,  here  find  their 
usefulness  in  teaching  simple  and  useful 
occupations  to  these  men.  The  teachers  them- 
selves will  have  to  be  trained  in  many  or  most 
instances,  but  it  takes  a  short  time  to  learn 
enough  of  basket  making,  knitting,  block 
printing,  weaving  (hand  looms  and  bead 
looms),  etc.,  to  teach  a  man  who  does  not 
know  the  first  rudiments  of  such  things.  In 
this  line  of  work  comes  the  first  introduction 
to  vocational  training  and  it  serves  a  useful 
purpose  in  occupying  the  man  in  the  manu- 
facture of  something  which  can  be  used  by 
somebody  and  immediate  improvement  in 
morale  is  often  noticed. 

The  attitude  which  the  public  should  take 
toward  these  men  has  already  been  spoken  of 
but  not  less  important  is  the  attitude  which 
such  a  man  should  take  toward  himself. 
Self  pity  is  demoralizing  and  detrimental; 
courage  and  self-reliance  and  sanity  cannot 

23 


be  taught  by  lectures  but  in  the  helpful  stimu- 
lating attitude  of  those  who  come  into  con- 
tact with  these  men  in  the  early  days  of  their 
reconstruction.  Such  help  should  begin  as 
far  back  as  the  base  hospital  where  the  mental 
needs  of  the  soldier  should  be  met,  and  occu- 
pation if  possible  provided.  During  the  voy- 
age he  should  have  some  such  cheerful  com- 
panionship and  occupational  therapy  should 
be  at  hand  to  prevent  mental  demoralization. 

PHYSICAL  THERAPEUTICS 

The  therapeutic  measures  at  our  disposal 
which  have  proved  useful  in  such  injuries  in 
civil  life  in  the  past  and  have  shown  their 
value  in  war  conditions  are  as  follows: 

i.  Massage  is  used  to  restore  tone  to  the 
muscles,  stimulate  local  circulation,  to  loosen 
up  scars  and  diminish  swelling,  and  for  this 
need  we  must  educate  competent  operators. 
It  is  responsible  business  and  not  to  be  handed 
over  to  every  person  in  civil  life  who  calls 
himself  a  masseur.  A  school  must  be  estab- 
lished for  the  training  of  competent  operators, 
a  standard  of  excellence  must  be  decided  upon 
and  the  soldier  must  be  protected  against 
careless  and  perhaps  harmful  manipulation. 

2.  Medical  or  therapeutic  gymnastics  must 
be  given  with  a  purpose  of  improving  the 
general  condition,  of  increasing  resistance  to 
fatigue,  of  loosening  up  stiffened  joints,  of 
improving  the  strength  of  weakened  or 
paralyzed  muscles,  etc.  They  have  been  long 
recognized  as  effective  and  in  war  conditions 
have  proved  of  the  greatest  value.  They 
must,  however,  be  given  with  care,  skill  and 
judgment  by  competent  operators. 

3.  Mechanotherapy.  Another  depart- 
ment of  physical  therapeutics  would  consist 
of  what  would  be  called  mechanotherapy, 

24 


used  chiefly  for  the  mobilization  of  stiffened 
joints  and  development  of  weak  muscles 
where  machines  of  greater  or  less  complexity 
are  used  instead  of  manual  stretching  and 
manipulation.  The  pendulum  principle  has 
been  extensively  used,  the  rhythmical  swing 
and  graduated  force  being  effective.  Simple 
apparatus  is  devised  by  certain  men  to  suit 
their  own  needs1  and  complicated  ones  are  of 
the  type  of  the  Zander  apparatus. 

4.  Hydrotherapy.  In  physical  therapeutics 
would  be  included  hydrotherapy  or  water 
treatment  by  baths,  douches,  sprays,  etc., 
which  are  of  use  in  promoting  local  or  general 
circulation,  removing  local  congestion  and 
thickening,  and  stimulating  the  general  condi- 
tion. 

5.  Electricity.  Treatment  by  electricity  or 
electrotherapeutics  has  shown  itself  to  be  of 
value  in  nerve  injuries,  local  muscular  weak- 
ness, or  paralysis  and  similar  conditions. 

6.  Heat.  The  use  of  hot  air  and  radiant 
heat  from  gas-heated  ovens  and  from  electric 
light  bulbs  has  long  been  known  to  reduce 
local  congestion  and  swelling,  to  allay  local 
pain  and  tenderness,  and  to  diminish,  along 
with  the  other  measures  mentioned,  joint 
stiffness. 

7.  Games.  There  may  be  grouped  in  this 
division  of  physical  therapy  the  use  of  games, 
fencing,  bowling  and  similar  exercises  to  im- 
prove the  general  condition  and  to  mobilize 
partly  stiffened  joints. 

8.  Muscular  re-education.  Muscular  re- 
education or  functional  re-education  of  the 
physical  therapeutic  measures  is  the  last  to 
be  considered.  Here  the  attempt  is  made  to 
teach  muscles  to  resume  their  normal  func- 
tions, wholly  or  partly  lost  by  injury,  or  by 

1  Mackenzie.   Brit.  M.  J.,  1916,  Aug.  12. 

25 


so-called  shell  shock.  Long  recognized  as  of 
value  in  the  treatment  of  paralysis  it  has 
assumed  especial  importance  in  the  treat- 
ment of  the  returned  soldier  and  has 
been  particularly  elaborated  and  formulated 
by  Prof.  E.  A.  Bott  of  the  University  of 
Toronto.1 

Curative  workshops.  The  value  of  the 
measures  mentioned  under  physical  therapy 
cannot  be  overestimated  and  have  been 
demonstrated  as  never  before  in  the  case  of 
the  disabled  soldier,  but  these  measures  pos- 
sess the  disadvantage  of  monotony,  they  have 
no  definite  use  beyond  the  improvement  of 
the  individual,  and  carried  out  over  a  long 
period  the  soldier  loses  interest  and  becomes 
stale.  The  tendency  has  therefore  of  late 
arisen  to  substitute  for  them  some  occupation 
by  the  performance  of  which  some  of  the  same 
aims  may  be  accomplished,  and  this  intro- 
duces the  question  of  the  curative  workshop 
which  has  assumed  great  importance.  The 
introduction  to  the  curative  workshop  has 
been  offered  to  many  of  the  soldiers  by  a  pre- 
liminary use  of  bedside  occupation.  The 
curative  workshop  represents  the  most  im- 
portant and  the  newest  feature  of  the  second 
phase  of  reconstruction.  You  will  remember 
that  the  first  phase  concerned  itself  with  sur- 
gical repair  by  operation  or  treatment  or  both. 
The  second  phase  opened  with  bedside  occupa- 
tion already  described  to  which  succeeds  the 
curative  workshop,  which  completes  the 
second  phase.  The  third  stage,  not  yet  taken 
up,  deals  with  vocational  training.  These 
stages  overlap  and  are  naturally  not  wholly 
distinct.  They  are  repeated  here  in  the  hope 
of  making  a  new  and  rather  complicated  mat- 
ter a  little  plainer. 

Univ.  Toronto  Monthly,  1017,'  April. 

26 


Sir  Alfred  Keogh,  K.C.B.,  formerly  Director 
General  of  the  British  Army  Medical  Service 
speaks  of  the  curative  workshop  as  follows:1 
"Nothing  has  been  more  remarkable  than  the 
overthrow  of  the  old-fashioned  purposeless 
orthopedic  exercises  for  the  cure  of  muscle 
weakness,  stiff  joints,  etc.  Under  the  influ- 
ence of  Colonel  Sir  Robert  Jones,  C.B.,  useful 
manual  work  has  largely  supplanted  the  older 
system  of  mechanotherapy.  The  bench,  the 
workshop,  and  the  gymnasium  provide  for 
the  active  movements  of  joints  and  of  limbs, 
in  contradistinction  to  the,  for  the  most  part, 
passive  movements  of  the  appliances  hitherto 
in  use,  while  at  the  same  time  the  patient, 
being  provided  with  a  useful  occupation,  lends 
himself  more  readily  to  the  treatment  pre- 
scribed for  him  and  becomes  interested  in  it. 
The  chief  point  to  remember  is  that  each 
piece  of  work  performed  is  a  prescription 
ordered  by  the  surgeon  for  a  specific  joint  or 
muscle  disability. " 

Colonel  Sir  Robert  Jones,  Inspector  of 
Military  Orthopedics,  who  is  in  large  measure 
responsible  for  the  development  of  the  cura- 
tive workshops  says:  "  As  soon  as  the  patient 
is  fit  to  get  about  he  should  have  some  occupa- 
tion both  for  his  mental,  moral  and  physical 
welfare.  Here  the  curative  workshop  is  an 
invaluable  aid  to  his  gymnastic  treatment. 
.  .  .  Excellent  and  useful  as  systematic 
gymnastic  training  is  for  developing  move- 
ment, the  training  in  co-ordination  in  doing 
purposeful  work  is  what  really  brings  brain 
and  muscle  once  more  into  proper  accord, 
while  regular  daily  work  re-establishes  in  the 
patient  habits  of  responsibility  and  self  respect 
...  for  example  a  man  with  stiff  fingers 

1  Bulletin  No.  6.    Federal  Board  for  Vocational  Education,  1918, 
Feb.,  p.  46. 

27 


barely  able  to  grasp  even  fairly  large  objects, 
is  soon  utterly  wearied  if  set  to  grasp  spring 
dumb  bells  or  any  other  such  apparatus,  but 
will  cheerfully  spend  the  morning  grasping 
a  big  duster  and  cleaning  windows.  .  .  . 
Later  if  he  is  a  carpenter  or  other  skilled 
tradesman,  he  is  promoted  to  the  use  of  tools 
he  understands,  and  so  the  disabled  is  re- 
educated partly  by  set  gymnastic  exercises 
and  largely  by  work.  Driving  a  plane  in  the 
carpenter's  work  can  be  employed  for  exer- 
cising muscles  and  joints  in  both  arms  and 
legs.  .  .  .  His  brain  is  interested  in  what  his 
hands  are  doing  and  not  wearied  by  the  cura- 
tive action  which  the  trade  brings  about." 

In  the  choice  of  the  special  department  of 
the  curative  workshop  to  which  the  man  shall 
be  first  assigned  depends  almost  wholly  on  the 
therapeutic  needs  of  that  man.  It  may  be 
that  he  requires  only  occupation  for  his  gen- 
eral physical  and  mental  condition  to  enable 
him  to  resist  fatigue  better,  to  improve  his 
circulation  and  muscle  tone.  For  such  men  it 
matters  little  which  of  the  divisions  of  the 
work  they  take  up,  but  in  general  it  is  obvi- 
ously desirable  for  them  to  take  up  some 
occupation  which  would  be  preliminary  and 
introductory  to  their  vocational  training.  If 
the  man,  on  the  other  hand,  has  stiff  joints  or 
shortened  muscles,  then  his  assignment  in  the 
curative  workshop  must  be  made  with  much 
care.  The  most  common  trades  used  in  such 
shops  are  carpentry,  metal  work,  the  use  of 
lathes,  leather  work,  cobbling,  tailoring,  net 
making,  basket  making,  drafting,  etc. 

In  cases  where  the  curative  workshop  is 
used  mainly  for  loosening  up  joints  and 
muscles  the  application  would  be  much  as 
follows:  If  the  wrist  is  stiff  and  the  circulation 
of  the  hand  poor,  the  use  of  a  carpenter's  plane 

28 


is  prescribed  which  will  necessitate  the  use  of 
both  fingers  and  hands.  The  stroke  at  first 
will  be  short  but  as  it  is  lengthened  it  exer- 
cises more  effect  upon  both  wrist  and  fingers. 
If  pronation  and  supination  are  limited  the 
board  to  be  planed  may  be  slanted  more  and 
more  which  exercises  a  new  line  of  force.  If 
the  elbow  is  stiff  the  patient  starts  using  a 
saw  with  a  short  blade  and  the  length  of  the 
saw  and  the  length  of  the  stroke  are  gradually 
increased  to  exercise  more  force  upon  the  stiff 
elbow.  Other  carpenter's  tools  of  use  for 
their  corrective  effect  on  arm  and  hand  are 
the  gimlet  or  screwdriver,  the  bit  stock,  etc. 
Basket  work  and  net  making  are  excellent 
for  loosening  up  stiff  fingers.  For  stiff  ankles 
and  knees,  pedal  driven  fret  saws,  foot  lathes 
or  foot-driven  machines  of  almost  any  nature 
mobilize  the  joints  of  the  lower  extremity. 
In  the  curative  workshop,  utilized  only  as 
such,  there  need  be  very  few  trades,  carpentry 
being  the  most  generally  applicable  and  the 
material  output  is  not  important  because  the 
main  object  is  therapeutic.  The  curative 
workshop  is  situated  in  the  reconstruction 
hospital  and  is  more  closely  affiliated  to  the 
medical  than  to  the  vocational  aspect  of  the 
work,  because  its  use  is  to  replace  and  supple- 
ment such  measures  as  massage,  etc.,  which 
would  naturally  come  into  the  medical 
division.  In  general  the  medical  division 
of  the  work  would  run  through  the  curative 
workshop,  and  in  the  period  of  vocational 
training  the  vocational  adviser  would  be  in 
charge.  But  there  must  needs  be  over- 
lapping, and  the  vocational  trainer  would 
probably  have  the  technical  administration 
of  the  curative  workshop  to  carry  out  the 
prescriptions  of  the  medical  officer.  The 
medical  officer  would  naturally  be  consulted 

29 


as  to  the  man's  capacity  for  one  or  another 
form  of  vocational  training.  In  this  over- 
lapping would  be  found  common  ground  for 
both  medical  and  vocational  experts. 

As  to  the  size  of  the  problem  of  vocational 
re-education,  the  estimates  of  the  Federal 
Board  of  Vocational  Training  in  their  report 
of  February,  1918,  are  as  follows:  "The 
latest  report  of  Canadian  experience  states 
that  practically  10  per  cent  of  the  Canadian 
forces  overseas  have  been  returned  as  unfit 
for  military  service.  ...  Of  the  men  re- 
turned unfit  for  military  service  80  per  cent 
or  four-fifths,  return  to  their  former  occupa- 
tions without  vocational  training  and  20  per 
cent  require  vocational  training.  One-half 
of  those  requiring  vocational  training,  re- 
quire complete  vocational  education,  and  one- 
half,  partial  vocational  re-education.  Ac- 
cepting these  ratios  as  significant  for  the 
overseas  forces  of  the  United  States  and  as- 
suming that  the  United  States  will  send  over 
1,000,000  men  the  first  year  and  will  increase 
its  expeditionary  force  by  1,000,000  each 
year  for  the  duration  of  the  war.  The  follow- 
ing deductions  are,  perhaps,  warranted,  as 
forecasting  conditions  at  the  close  of  one 
year  of  fighting. 

Number  of  men  overseas 1,000,000 

Number  of  men  returned  unfit  for  military 
service 100,000 

Number  not  requiring  vocational  re-educa- 
tion   . . .      80,000 

Number  requiring  vocational  re-education, 
complete 10,000 

Number  requiring  vocational  re-education, 
partial 10,000 

In  a  word,  for  each  million  men  overseas 
it  may  perhaps  fairly  be  expected  that  100,000 
men  will  be  returned  each  year,  of  whom 
20,000     will    require     complete    or    partial 

30 


vocational  re-education.  This  number  of 
men  may  in  fact  be  in  hand  to  be  provided  for 
by  the  close  of  the  summer  campaign  of  1 918." 
It  is  evident  therefore  that  the  question  of 
vocational  training  must  be  taken  up  on  a 
large  scale  and  first  one  must  consider  certain 
aspects  of  the  matter  which  seem  funda- 
mental. These  are:  (1)  The  new  trade 
should  be  so  far  as  possible  affiliated  to  and 
like  the  former  occupation.  Instances  of  this 
would  be  where  a  house  painter  would  be- 
come a  sign  painter;  a  barber  a  wig  maker;  a 
mason  or  a  carpenter  a  draftsman  or  archi- 
tect's clerk.  The  house  painter  with  disabled 
legs  would  make  a  poor  wigmaker  and  the 
barber,  a  poor  sign  painter.  A  mechanic  was 
earning  three  dollars  a  day  before  the  war  and 
was  disabled.  He  was  given  a  course  of  ten 
weeks  in  mechanical  drawing  and  now  earns 
twice  as  much.  (2)  The  new  occupation  if  it 
cannot  closely  resemble  the  old  one,  should 
be  one  adapted  to  the  individual's  capacity 
and  education.  This  is  less  important  than  it 
might  seem  because  the  experience  of  a  year 
in  Belgium  has  seemed  to  show  that  the  choice 
ofjthe  original  occupation  was  usually  hap- 
hazard (De  Paew).  As  examples  of  this 
change  of  occupation,  a  waiter  whose  right 
arm  was  disabled  took  up  sign  painting  with 
his  left  hand  and  in  six  months  became  a 
master  workman.  A  clown  disabled  for  the 
ring  became  a  most  successful  ornamental 
printer.  A  man  before  the  war  had  driven  a 
team  and  worked  on  a  pile  driver  at  fifteen 
to  eighteen  dollars  a  week  and  is  now  earning 
thirty  dollars  as  a  machinist.  (3)  The  occupa- 
tion should  be  one  in  which  there  will  be  a 
demand  for  workers  after  the  war.  This,  of 
course,  is  self-evident,  but  further  than  this, 
the  man  should  be  educated  along  the  lines 

31 


/ 


for  which   there   is   demand  in  his   special 
community. 

The  man  whose  home  is  in  the  country 
would  be  educated  along  agricultural  lines 
and  the  man  from  the  large  cities  in  manu- 
facturing, salesmanship,  stenography,  etc. 
This  need  is  not  compelling  but,  in  general, 
an  occupation  should  be  selected  which  would 
not  necessarily  mean  a  change  of  residence. 
(4)  In  certain  instances  the  man's  special 
technical  vocational  training  must  be  pre- 
ceded by  some  general  education  in  such 
fundamental  studies  as  reading,  writing  and 
arithmetic,  which  will  enable  him  to  qualify 
for  some  position  not  necessitating  manual 
labor  for  which  he  may  have  been  wholly  in- 
capacitated. A  soldier  writes,  "When  I 
came  back  from  the  front  in  October,  191 6, 
I  was  not  able  to  read  or  write.  .  .  .  Before 
the  war  I  was  driving  a  team  at  fifteen  dollars 
a  week."  He  took  a  course  in  the  machine 
shop  at  McGill  and  says:  "If  it  had  not  been 
for  the  school  I  never  would  have  been  in  the 
place  where  I  am  today,  and  I  expect  to  get 
about  thirty  dollars  a  week." 

The  selection  of  a  new  occupation  will  rest 
with  the  vocational  director  after  consulting 
with  the  surgeon  as  to  the  man's  special  dis- 
ability. The  director  talks  with  the  man, 
makes  a  survey  of  his  education  and  previous 
trade,  his  mentality  and  his  tastes,  tells  him 
of  the  successes  of  other  re-educated  men  and 
encourages  him  to  ambition  and  hopefulness. 
At  Port  Villez  in  Belgium,  for  instance,  after 
this,  the  man  is  allowed  to  visit  the  workshops 
where  there  are  forty-eight  trades.  He  walks 
about  them,  talks  to  the  men  employed,  and 
is  given  two  or  three  days  to  consider  the 
matter.  He  then  comes  before  a  board  con- 
sisting of  the  surgeon,  the  technical  director 

32 


and  the  vocational  director  and  with  their 
assistance,  chooses  a  trade  provisionally  in 
which  he  goes  to  work.  If  this  proves  un- 
suitable he  may  change,  but  changing  and 
uncertainty  are  discouraged.  There  are  two 
practical  obstacles  found  on  the  part  of  the 
soldier  to  vocational  training.  First,  laziness, 
and  second,  the  fear  that  if  he  is  physically 
improved  his  pension  will  be  cut  down.  This 
latter  matter  has  been  dealt  with  by  provi- 
sions that  the  man's  pension  is  estimated  on 
his  original  injury  and  is  not  affected  by  his 
improvement.  This  is  regarded  in  Canada  as 
so  important  that  in  convalescent  homes  and 
hospitals  there  is  posted  a  statement  that 
pensions  depend  solely  upon  degree  of  dis- 
ability and  are  not  influenced  by  increased 
earning  power. 

The  trades  which  are  taught  need  not  be 
mentioned  individually.  They  may  be  divided 
roughly  into  three  groups. 

i.  Industrial.  Trades,  machine  work, 
blacksmithing,  metal  work,  carpentry,  tailor- 
ing, brushmaking,  shoemaking,  leather  work, 
box  making,  toy  making,  bookbinding, 
manufacture  and  repair  of  artificial  limbs,  etc. 

2.  Commercial.  Clerical  occupations.  Sten- 
ography, telegraphy,  designing,  bookkeeping, 
mechanical  drafting,  etc. 

3.  Agricultural  pursuits. 

Placement.  Finally  comes  the  terminal 
stage  of  vocational  training,  that  of  placing 
the  man  in  a  permanent  position.  Here  again 
the  public  and  through  it,  the  manufacturers, 
must  be  "educated  to  paying  the  country's 
debt  to  these  men  by  employing  them.  There 
is  to  be  met  the  natural  reluctance  of  the 
manufacturer  to  employ  a  man  for  whom  he 
fears  he  may  have  to  make  allowances  and  the 
possible  opposition  of  labor  with  regard  to 

33 


these.  The  statement  is  made  in  American 
Industries  for  October,  191 7:  "  There  is  an 
almost  universal  willingness  on  the  part  of 
manufacturers  to  give  every  opportunity  to 
our  workers  who  may  be  injured  or  crippled 
in  the  war."  F.  W.  Keogh,  editor  of  A  merican 
Industries,  the  organ  of  the  National  Associa- 
tion of  Manufacturers  in  a  recent  speech 
quoted  the  president  of  that  association  as 
saying:  "I  am  first  an  American  and  a  pa- 
triot and  as  such  I  will  aid  these  men  in  every 
way  possible.  I  am  also  a  manufacturer  with 
economical  responsibilities  to  my  stock- 
holders, employees  and  others,  and  as  such 
I  cannot  consider  these  men  as  employees 
unless  I  am  convinced  it  is  a  sound  business 
proposition."  Fortunately  evidence  so  far 
collected  proves  that  the  disabled  soldier  can 
return  to  industry  as  a  sound  business  proposi- 
tion for  the  manufacturers  and  for  this  reason 
it  is  essential  that  his  training  should  be 
thorough  so  that  in  the  years  following  the 
war  he  may  be  able  to  hold  his  own. 

The  attitude  of  labor  toward  these  men  is 
also  a  great  factor.  The  general  attitude  of 
the  British  labor  party  as  to  treatment  of 
disablement  by  war  is  that  every  possible 
opportunity  should  be  offered  for  securing 
the  best  treatment  and  that  every  appliance 
that  science  can  suggest  should  be  devoted  to 
the  restoration  and  aid  of  those  who  have 
become  disabled1  and  the  labor  party  favors 
the  opening  up  of  every  possible  avenue  of 
training  to  every  man  who  desires  to  avail 
himself  of  it.  The  British  trades  unions  are 
not  only  sympathetic  but  desire  to  assist  the 
disabled  man  in  every  possible  way  to  secure 
employment  on  remunerative  work  provided 


1  Monthly  Review  United  States  Bureau  of  Labor  Statistics.   1917, 
Dec. 

34 


that  there  should  be  no  dimunition  in  the 
standard  of  living  or  possibility  of  the  dis- 
abled man  being  used  to  defeat  the  legitimate 
objects  which  the  trade  unions  have  in  view. 
The  man's  first  placement  is  of  importance 
because  no  subsequent  one  will  be  so  easily 
brought  about. 

The  requirements  for  success  in  the  whole  of 
vocational  re-education  are  judicious  selection 
of  the  new  trade,  the  utmost  thoroughness  in 
training,  care,  and  discretion  in  placement. 

Training  of  teachers.  The  training  of  teach- 
ers for  bedside  occupation,  curative  work- 
shops and  vocational  training  and  especially 
finding  men  for  the  responsible  post  of  voca- 
tional directors  is  another  of  the  problems 
confronting  us.  The  Federal  Board  for  Voca- 
tional Education  estimates  that  four  teachers 
will  be  needed  for  every  hundred  disabled 
soldiers,  and  regards  this  as  an  undesirably 
low  figure.  On  this  basis,  for  every  million 
men  overseas,  there  will  be  required  here 
1 200  such  teachers.  The  provisions  for 
educating  these  teachers  are  being  considered 
by  the  Federal  Board  for  Vocational  Training 
as  presented  in  a  special  Bulletin  No.  5.    ,_ 

Industrial  accidents.  There  will  be  a  by-' 
product  of  the  war  and  its  experiences  which 
has  been  mentioned,  and  this  is  the  fact  that 
rehabilitation  of  those  disabled  in  the  indus- 
tries will  in  the  future  be  practised  in  the  light 
of  what  we  shall  have  learned  from  the  re- 
habilitation of  those  disabled  in  war.  In  19 13 
there  were  700,000  industrial  accidents  in  the 
United  States  involving  more  than  a  four 
weeks  disability.  In  Scandinavia,  Belgium, 
and  France,  there  existed  before  the  war 
trade  schools  for  the  re-education  of  those 
crippled  by  industrial  accidents.  There  were 
also  schools  in  Petrograd  and  Munich,  but 

35 


in  this  country  the  matter  has  never  received 
serious  consideration.  Professor  Amar  may- 
be quoted  as  saying:  "The  war  will  be  over 
but  the  industrial  work  and  the  necessity  for 
the  scientific  study  and  physical  organization 
of  it  will  be  with  us  forever."  A  report  of  the 
Federal  Board  for  Vocational  Re-education 
summarizes  the  matter  of  our  negligence  as 
follows:  "It  is  certain,  however,  that  our 
economic  future  depends  to  a  large  extent 
upon  the  rehabilitation  of  those  disabled  both 
in  war  and  industry.  .  .  .  The  time  has 
passed  when  the  supply  of  skilled  labor  is  as 
inexhaustible  as  our  natural  resources  were 
thought  to  be.  We  can  no  longer  afford  to 
continue  our  former  wasteful  methods  and  we 
must  conserve  every  vestige  of  labor  as  an 
economic  asset."  (Bulletin  No.  6.)  The  prob- 
lem of  the  industrial  cripple  cannot  be  lightly 
dismissed  for  its  size  and  economic  importance 
are  very  great.  From  a  study  of  industrial 
accidents  in  sixteen  states,  figures  made 
available  by  the  publication  of  state  bureaus, 
checked  up  by  the  standard  accident  table 
and  Bulletin  203  of  the  Department  of  Labor, 
Rubinow  drew  the  following  conclusions: 
Of  the  26,136,676  employees  in  the  different 
states  covered  or  not  covered  by  the  com- 
pensation law,  there  are  about  1,900,000  non- 
fatal accidents  per  year.  Estimating  the 
number  of  permanent  disabilities  produced 
annually  by  industrial  accidents  in  the  United 
States,  Rubinow1  arrived  at  a  mean  estimate 
of  about  83,000  per  year.  In  191 6  there  were 
injured  on  the  steam  railroads  196,722,  not 
counting  10,000  deaths,  and  on  the  electric 
roads  4,606.  That  is  practically  200,000 
people.    Naturally  many  of  these  accidents 


1  Publication  of  the  Red  Cross  Institutions  for  Crippled  and  Disabled 
Men,  Series  6,  No.  4. 

36 


were  unimportant  and  not  disabling  but  in 
200,000  injured  on  steam  or  electric  cars  there 
would  obviously  be  a  fair  proportion  of  dis- 
abled persons.  In  April/  19 16,  the  Phila- 
delphia branch  of  the  Pennsylvania  State 
Bureau  of  Employment,  established  a  depart- 
ment for  the  placement  of  handicapped 
workers  and  visited  fifty-five  of  the  leading 
industrial  firms  in  Philadelphia  and  made 
"  progress  toward  overcoming  the  innate 
prejudice  against  the  employment  of  crip- 
ples." Many  instances  are  given  of  workers 
thus  placed  who  are  earning  surprisingly 
good  wages. 

SUMMARY 

The  difficulty  of  presenting  this  question 
of  reconstruction  must  be  evident.  It  is  a 
new  subject,  only  in  its  formative  stage  as 
yet,  practically  dating  from  191 5.  There  are 
many  disputed  points  and  many  matters  of 
policy  yet  unsettled  and  no  mechanism  has 
existed  in  the  past  for  formulating  and  carry- 
ing on  the  demands  which  must  be  met. 

In  this  matter  we  are  not  discussing  a  new 
form  of  charity,  but  are  trying  to  formulate  a 
plan  to  discharge  a  pressing  obligation. 
Success  depends  upon  sound  public  senti- 
ment, and  sentimentality  and  emotionalism 
have  no  place  in  the  scheme ;  the  government, 
the  public,  the  manufacturer,  the  labor  unions 
and  the  medical  profession  must  join  hands, 
and  different  points  of  view  must  be  mini- 
mized for  the  common  welfare.  This  is  no 
small  question  which  we  face;  it  would  be 
better  for  most  of  the  seriously  wounded  men 
to  die  on  the  battlefield  than  for  us  to  fail  in 
our  duty  of  efficiently  caring  for  them  and 
restoring  them  to  the  highest  possible  degree 

1  Am.  J.  Care  of  Cripples,  191 7,  June. 

37 


of  economic  efficiency.  Let  us  hold  up  the 
hands  of  the  Government  in  carrying  out  the 
carefully  formulated  and  studied  plans  which 
will  be  announced  in  due  time  and  let  us 
remember  that  destructive  criticism  is  easy 
and  constructive  organization  difficult. 


Reprint  from 
SURGERY,  GYNECOLOGY  AND   OBSTETRICS 

August,  i pi 8,  pages  i6q-i8i. 


38 


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